Portacaval anastomosis (PCA) has been the standard treatment of patients who have bled from varices for the past 25 years. Recent controlled investigations of PCA have shown that although this operation has virtually eliminated hemorrhage from varices, it has failed to improve survival significantly. In effect it substituted deaths from hepatic failure and portal-systemic encephalopathy (PSE) for deaths from hemorrhage. It has been postulated that post-shunt hepatic failure and PSE result from deprivation of hepatotrophic substances in the portal blood. Warren, et al devised the distal splenorenal shunt (DSRS) to decompress varices without interrupting portal blood flow to the liver. Preliminary reports indicate that DSRS, although difficult and of higher operative mortality than PCA, prevents further bleeding without inducing PSE. We are performing a controlled, randomized investigation comparing PCA and DSRS in patients who have survived variceal hemorrhage jointly with our associates in Boston at the Lemuel Shattuck, New England Deaconess, St. Elizabeth's and Faulkner Hospitals. In the past 68 months we have operated on 60 patients, and the operative mortality in the PSS and DSRS groups is similar (4 and 12 percent respectively). The incidence of PSE is similar also, having occurred in 28 and 27 percent, respectively, of patients discharged from the hospital after PSS and DSRS. We propose to continue this study for 4 years to achieve a total of 80 randomized patients. In the course of this study we are comparing prospectively the frequency and pathogenesis of a number of "complications" of portacaval anastomosis that have been attributed to portal-systemic shunting and/or deprivation of portal blood flow. These include (1) PSE, (2) post-shunt hepatic failure, (3) peptic ulcer disease, (4) hemosiderosis, (5) diabetes. In addition, we are comparing the effect of these two operations on hypersplenism. We are studying the effect of these two operations on hepatic hemodynamics, portal pressure and portal-systemic collateral flow. Finally, we are comparing angiographic and ultrasonographic techniques in assessing the patency of the different types of shunts.